Ann Thorac Surg 2002;74:1718-1719
© 2002 The Society of Thoracic Surgeons
How to do it
Two-patch repair of complete atrioventricular septal defect using a small ventricular patch
Takaaki Suzuki, MDa*,
Toyoki Fukuda, MDa
a Division of Cardiovascular Surgery, Tokyo Metropolitan Children’s Hospital, Tokyo, Japan
Accepted for publication May 1, 2002.
* Address reprint requests to Dr Suzuki, Division of Pediatric Cardiovascular Surgery, University of Michigan School of Medicine, F7830 Mott Children’s Hospital, 1500 E Medical Center Dr, Ann Arbor, MI 48109-0223, USA.
e-mail: suzukimd{at}blue.ocn.ne.jp
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Abstract
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Since 1992, 19 patients with an atrioventricular septal defect have undergone surgical treatment using a novel annuloplasty technique in which a small ventricular patch was used to reduce the anterior-posterior dimension of the atrioventricular orifice. All patients recovered uneventfully and needed no reoperation for the residual regurgitation or shunt. The results showed that the new annuloplasty technique was promising, although a long-term result is yet to be seen.
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Introduction
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Although the technical refinement and evolving concept of the complete atrioventricular septal defect have reduced the postoperative mortality, the high prevalence of the residual regurgitation of the atrioventricular (AV) valve remains to be solved [1, 2]. Our surgical strategy has been consistent since 1979, and we have used the two-patch repair of the defect and trifoliate reconstruction of the left AV valve. Recently, we have adopted a new annuloplasty technique in which a small ventricular patch has been used to reduce the anterior-posterior dimension of the AV valvar orifice [3, 4].
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Technique
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All patients underwent bicaval and aortic cannulation and were perfused with moderate hypothermia. Cardiac arrest was achieved by the repeated infusion of the cardioplegic solution. The surgical management was performed solely through the right atrium. The two-patch technique was used for closure of the defect without incision to the AV valvar leaflets or chordal structure. The ventricular component of the defect was repaired with a small Gore-Tex patch of 0.4 mm thickness (W. L. Gore & Associates, Flagstaff, AZ) using a single continuous suture (5-0 Prolene, Ethicon, Somerville, NJ). The patch was trimmed in a manner as to reduce the anterior-posterior dimension of the AV valvar annulus to 80% of the approximate size (Fig 1).
The anterior and posterior bridging leaflets were attached to the superior margin of the ventricular patch with a series of U-shaped sutures (5-0 Prolene, Ethicon). The same sutures were brought through the inferior edge of the atrial patch and secured, thereby sandwiching the inferior and superior bridging leaflets between the patches. The cleft of the left AV valve was partly closed with one or two interrupted sutures, thereby remodeling the valve into a trifoliate structure. In the presence of residual regurgitation, as was seen in 4 of our patients, one or more cleft sutures were added. Commissural annuloplasty was added when required. Complete closure of the cleft was performed on 3 patients (15.8%). An autologous pericardium was used for closure of the atrial component of the defect using a single continuous suture (5-0 Prolene, Ethicon). At the posterior AV valvar annulus, the stitches secured the inferior bridging leaflet so as not to jeopardize the neighboring conduction tissue (Fig 2).
The coronary sinus was kept on the right atrial side of the patch.
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Fig 1. (A) The anteroposterior length of the patch for the ventricular component of the defect was reduced to 80% of that of the atrioventricular valvular annulus.(B) The ventricular patch was secured using a single running suture. A small ventricular patch transformed the atrioventricular annulus into a physiologic configuration.
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Fig 2. The anterior and posterior bridging leaflets were sandwiched between the ventricular (Gore-Tex [W.L. Gore & Associates, Flagstaff, AZ]) patch and the atrial (autologous pericardium, shown as the cross signs) patch as a buttressing measure. The suture line along the posterior atrioventricular (AV) valvar annulus was placed so as not to jeopardize the neighboring conduction tissue. The cleft of the left AV valve was partly approximated by one or two interrupted sutures.
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Between December 1992 and November 2000, 19 patients with the complete atrioventricular septal defect underwent the definitive surgical repair with the new annuloplasty technique. Age and weight at the time of operation ranged from 1 to 32 months old (median, 7 months old) and from 1.7 to 14.6 kg (median, 5.3 kg), respectively. The morphologic feature of the AV valve was Rastelli type A in 9 patients (47.4%) and type C in 10 patients (52.6%). There was 1 hospital death caused by pulmonary hypertensive crisis. One late death occurred due to a noncardiac reason. Regurgitation of the left AV valve was evaluated by the Doppler technique of echocardiography and was graded as none, trace, mild, moderate, or severe. Preoperatively, the regurgitation was none or trace in 16 patients, mild in 2 patients, and moderate in 1 patient. At the latest follow-up, ranging from 2.8 to 99.4 months (median, 46.7 months), the regurgitation was none or trace in 16 patients (88.9%) and mild in 2 patients. Reoperation for the residual regurgitation or shunt was not needed in any of the patients. As for the right AV valve, regurgitation of greater than mild in degree occurred in only 4 patients (22.2%). No pacemaker implantation was required.
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Comment
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Despite intricate modifications of the surgical technique for atrioventricular septal defect, the high prevalence of the residual regurgitation of the left AV valve has been an issue of concern [1, 2]. Indeed, how to manage the cleft of the left AV valve has long been a matter of controversy. This in turn may reflect on the current issue as to whether the left AV valve is better to be transformed into a two-leaflet valve or a three-leaflet valve. Although most recent studies tend to favor the bifoliate reconstruction [5], one of the current studies shows that the reoperation rate for the residual regurgitation was not different between the two reconstructive techniques [2]. We have consistently reconstructed the valve into a trifoliate fashion. The present study supports the earlier view [2, 6] that the annular dilation is the primary reason for the poor apposition of the anterior and posterior bridging leaflets with consequential regurgitation of the left AV valve. Moreover, the cardiac skeleton of atrioventricular septal defect is characterized by the elliptic form AV valvar annulus and unwedged position of the aortic annulus. Therefore we infer that a combination of dilation and unique configuration of AV valvar annulus predisposes poor apposition of the AV valvar leaflet. With these considerations in mind, we have adopted the present technique in which a small ventricular patch is used to reduce the anterior-posterior dimension of the AV valvar orifice. In our understanding, remodeling of the AV annulus not only reduces the annular size, but also brings both bridging leaflets together with consequence of better coaptation of the valve. Accordingly, partial approximation of cleft may be preferable to achieve homogenous apposition of the bridging leaflets and large opening of the left AV valve.
In conclusion, a combination of the two-patch technique for closure of the defect using a small ventricular patch and partial approximation of the cleft is a safe and promising surgical method with which we can reduce the prevalence of the residual regurgitation of the left AV valve.
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References
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- Capouya E.R., Laks H., Drinkwater D.C., Pearl J.M., Milgalter E. Management of the left atrioventricular valve in the repair of complete atrioventricular septal defects. J Thorac Cardiovasc Surg 1992;104:196-203.[Abstract]
- Michielon G., Stellin G., Rizzoli G., Casarotto D.C. Repair of common atrioventricular canal defects in patients younger than four months of age. Circulation 1997;96(Suppl II):II-316-II-322.
- Shimada M., Sekiguchi A., Nagamine T., Tonari K., Matsuzaki M. Surgical repair of complete atrioventricular septal defect: annuloplasty by using a smaller VSD patch. Kyobugeka 1995;48:624-627.
- Oku H., Kitayama H., Matsumoto T. Valvulo and annuloplasty in correction of complete atrioventricular septal defect. Kyobugeka 1995;48:616-623.
- Tweddell J.S., Litwin S.B., Berger S., et al. Twenty-year experience with repair of complete atrioventricular septal defects. Ann Thorac Surg 1996;62:419-424.[Abstract/Free Full Text]
- Suzuki K., Tatsuno K., Kikuchi T., Mimori S. Predisposing factors of valve regurgitation in complete atrioventricular septal defect. J Am Coll Cardiol 1998;32:1449-1453.[Abstract/Free Full Text]
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Abstract
Introduction
